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F0609
D

Failure to Timely Report Alleged Abuse to State Authorities

Murrieta, California Survey Completed on 07-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of abuse by a Certified Nursing Assistant (CNA) towards a resident was reported to the California Department of Public Health (CDPH) within the required timeframe. On the morning of May 26, a Licensed Vocational Nurse (LVN) observed the CNA providing care to a resident in an aggressive and forceful manner, with the resident screaming in pain and stating he was hurt. The LVN reported the incident to the Administrator and the Assistant Director of Nursing (ADON), and the CNA was suspended from duty. However, the LVN did not complete the required abuse documentation or notify CDPH as mandated by facility policy and state regulations. The Administrator became aware the following morning that the abuse allegation had not been reported to CDPH within the required two-hour window. The Administrator then notified CDPH about the incident on May 27, which was outside the mandated reporting timeframe. The facility's policy and state and federal guidelines require that all allegations of abuse be reported to the appropriate authorities immediately or within two hours if serious bodily injury is suspected, or within 24 hours otherwise. The resident involved was described as frail, confused, and suffering from dementia and Parkinson's disease, requiring significant assistance with mobility. Documentation and interviews confirmed that the resident was subjected to rough handling by the CNA, and that the mandated reporting process was not followed in a timely manner, as required by both facility policy and regulatory guidelines.

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